Desperately need time management tips!

[NTPinky]

Hi all,

I orinally posted this in the "First Year in Nursing" forum but I think it belongs here since I need advice from experienced RNs.

Anyway, I'm a new grad on a busy med-surg floor, day shift (yuck). I would have preferred nights but oh well, this is what I'm stuck with until I quit, which will be sooner rather than later. In the meantime, I desperately need to figure out how to manage my time! There's one senior RN who's always begging me to go eat or take a break, and I always say I can't because I'm always behind, and we don't get paid for overtime so I want to get out as fast as I can at the end of the day.

Things start out ok at the beginning of the shift but things get nuts and I feel so stressed. I've been modeling my preceptors' behaviors and they way they do things, but it doesn't work for me. This is their routine, and the model I've followed:

1. After getting report, do AM chart checks. This is where we check the previous shift's charting to make sure orders were entered into the computer and/or carried out by the previous RN.
   
2. Get the labs for each pt from the unit clerk, report any critical labs to the MD.
   
3. Go to the MAR of each chart and on the report sheet, jot down the times of the meds due for each pt.
   
4. Pull out the MAR for the first pt and their meds. Administer that pt's meds, and then do the assessment.
   
5. Repeat #2 and #3 for the rest of the pts (usually all 5 pts have their first meds due at the same time, i.e. 9AM)
   
6. Chart all the assessment findings and a short narrative on the nursing flowsheet. If any pain meds are given during the shift, document on the pain mgmt flowsheet and follow-up with the pt 10-30 mins later to re-evaluate their pain), and chart on the re-evaluation
   
7. Enter pt acuity in the computer system (must be done by 11am)
   
8. Near the end of shift, do final charting on the nursing flowsheet.
   
9. Close charts (do 8-hr chart check, if any new orders done after 14:30, endorse to the PM shift).

It doesn't seem like much on paper, but I find it so overwhelming. This is how all the experienced RNs do it and they always have time for breaks and lunch, yet I struggle and am always behind despite the fact that I never take breaks or lunch, or even go to the bathroom. Factor in all the other crap that goes on during day shift, like dealing with all the MDs, case managers, social workers, phone calls, etc., I don't know how to deal with it all. When I ask for help from the other RNs with certain tasks, most of the time they're too busy.

At 15:00 I stop to give report to the PM nurses, and then I have to go back and finish all the charting I didn't finish during the day! I wish they taught us time management in school, but maybe this is just one of those things you can't teach. If anyone has any pointers though, please share them. I've only been on my own for 2 days, and I have major insomnia from worrying so much about what mistakes I possibly made during my shift. Please help!

Thanks so much!

[TheCommuter, BSN, RN]

I'm an LVN on a fast-paced rehab unit so my tips may not be of much use to you, since our specialties and duties might differ to a certain extent. However, here are my time management tips, and I hope they can help in even a small way.

Here is how I organize for the day. I work 16 hour shifts, from 6am to 10pm. Typically, I have about 15 patients to care for. At the beginning of the shift, I'll go through the MARs and TARs with a fine tooth comb and, as I go, I will jot down the things that must be done in my notebook. My notebook is how I organize the rest of the day, and I usually won't forget to do anything. Here is how Sunday's notebook page looked (names have been changed due to HIPAA):

10-28-2007

DIABETICS, FINGERSTICKS: Agnes (BID), Agatha (AC & HS), Bill (AC & HS), Wendy (AC & HS), Rex (BID), Jack (BID), Esther (AC & HS), Margie (0600, 1200, 1800, 2400)

NEBULIZERS: Margie, Esther, Bill, Jack, Jane

WOUND TREATMENTS: Jane, Bill, John, Jack, Lillian, Rose, Lucille

IV THERAPY: Wendy (Vancomycin), Laura (Flagyl), Rex (ProcAlamine)

COUMADINS: Agnes, Agatha, John, Lucille

INJECTIONS: Agnes (lovenox), Jane (arixtra), Rex (heparin), Bill (70/30 insulin), Esther (lantus), Mary (vitamin B12 shot)

ANTIBIOTICS: Wendy (wound), Laura (C-diff), Rex (pneumonia), Agatha (MRSA)

1200, 1300, 1400 meds: Margie, June, Rose, John, Jane, Jack

1600, 1700, 1800 meds: Rose, John, Rex, Lucille, Lillian, Laura

REMINDERS: assessments due on Agatha, Jill, and Louise; restock the cart; fill all holes in the MAR; follow up on Jane's recent fall, fax all labs to Dr. Smith before I leave, order a CBC on Rex...

[wooh, BSN, RN]

This is how all the experienced RNs do it and they always have time for breaks and lunch, yet I struggle and am always behind despite the fact that I never take breaks or lunch, or even go to the bathroom.

I got asked by a new nurse one day how I was already done with my charting. The experienced nurses aren't necessarily magical or have special tricks. We're just experienced. Our thought processes take half the time, because we've seen it before. Our charting takes half the time because we don't have to think about each system. I look at my kid, know I'll be charting this, this and this, and can quickly throw a check on all the other systems. I don't have to look up every med I give, and when I do, I don't have to think through as long why I'm giving it, it's just, "Oh yeah, it's for that."

Give it time, you'll move faster soon enough! (Although to be honest, for me it seems the more experience I get, the more work I seem to find for myself. So having more time balances out with having more that I feel I "need" to do.)

[angel_prias]

Can I please share some tips, too? :)

I am still in nursing school but when we are on the floor for RLE, we'd do everything a regular staff nurse would in his/her shift (except anything that has to do w/ IVs, etc.) and they'd make sure to give us patients that we need a lot to do to/for. But thank God, the student nurse to patient ratio is 1:1 or 1:2.

Anyway, here's what I do. I make an hourly sched on what to do. Something like this:

0730H - prep meds for 8AM, drug study

0800H - v/s, I/O, check IV level, am care, turn pt to right side, give meds

0900H - v/s, I/O, check IV level

1000H - v/s, I/O, check IV level, NGT feeding, 15-min break

1100H - v/s, I/O, check IV level, prep NGT feeding

and so on and so forth...

And I make sure I check the things I already did so I won't forgot.

Hope this helps. Good luck!

[DudeNurseRN]

Yup it's tough. They don't teach you about the reality of things in nursing school. Your unit sounds kinda similar to mine in some aspects.

My general suggestions:

Shift start to 0745

* Assess pt's pain and nausea/vomiting (like 20 seconds with each person)1st and foremost so you can get the PRN pain/nausea meds out with the 1st scheduled batch, but don't bother with the lung or bowel assessments right away if there are no obvious problems.

0745-0900

*Give all "busy time" morning medications and perform focused assessments on those who are most in need, wait on the lungs and gut for those people who are obviously stable.

0900-1000

*NOW, sit down and chart all your "busy time medications" and the assessments that you were able to perform, and start your progress notes, but save them and realize that you can add a little bit more when you have time. Try do your acuities now. 3/4 of your documentation at this point can be finished/a work in progress.

1000-1100

*Reassess pain relief, and peform the assessments that you have been waiting on. After this, document your assessments, add to your progress notes and try and take a little breaky break around 1045.

1100-1200

*Change function to: grab scheduled/prn meds and document right away after giving them since there is a lot less of them at this point. Get your progress notes about 3/4 done to finished.

1200-1300

Grab your lunch for 30 minutes or whatever sometime in here. Checkup on your people, spend some time with them, and do dressing changes and whatnot. Grab meds and document as needed of course.

REALIZE HERE THAT, if things are going to get busy/poo hit the fan, it's going to be in the last 2 hours of your shift, and that's why you need to have everything close to finished

1300-1400

Give report somewhere in here, realize that you can always add/ask someone if they have any questions when they come out of report. Finish up your progress notes.

Attend to needs, help PCA/NA's if you can.

1400-1530

Do whatever you can for your patients, if you need to spend a little extra time with someone, try to put it here at this point in the day. Answer/update your relief nurses as they come to the floor (realize that, that is what these people are here for is to relieve you). Say your goodbye's and checkout.

Easier said than done, takes practice, but definately doable. In general these suggestions from my charge RN, who has worked on my unit for 30 years, have helped me immensely to get home on time to see my family and have my day a little bit better planned out.

Hope this helps some.

[NTPinky]

Thanks so much for the suggestions. DudeNurse, I'm going to try out your schedule tomorrow and over the weekend.

I should have added in my original post that we don't get relief nurses for breaks/lunch, we have no LVNs on our floor, and most of the time only one CNA for the whole floor. I live in CA and because of the ratios, they're phasing out the CNAs/LVNs. I'm already struggling with the 1-2 CNAs we get (they do SO much!), so just thinking about what it'll be like when they're gone makes my stomach turn. I've seen people in some of the other forums talking about how they want to move to CA because of the ratios. Ha!

I'm going to talk to the RN in charge of scheduling tomorrow to see if anything is available on night shift. I don't know if things are any less stressful on night shift, but it'd be nice not having MDs, case managers, social workers, etc in my face all day! If there isn't anything on night shift, I feel I'll have to resign. I'm terrified that I'll lose my license if I stay (my orientation was only 5 weeks and it wasn't very thorough).

Please keep the suggestions coming and thanks for everyone's tips so far.

[KulRN]

I've only been in practice for a little over 2 years and believe me I still struggle with time management at times...but I still somehow get out in time...Here's how I do my day (7A-7P shift):

0653 I get my assignment (normally I have 8 patients with an LVN and a Tech), I look at all my patient's labs in the computer ( I religiously do this before I get my report)

0700 I get report from the night shift ( I like to do bedside report so I can see my patients...mini assesment.. and point out anything questionable to the night RN)

0730 I go to the patients bedside chart to check their meds and the ones I have to give ( LVN gives PO meds) and patients vitals signs and previous I/O's

0745-1730 From my mini assesment, I now go do my assesment on the ones I feel needs to be seen first (priority)..FYI: when I perform my assesment I don't do head to toe unless it's called for. I focus on what they're in for...I do my assesment all day long without having to spend a whole lot of time...even when I'm hanging an antibiotic or just handing pen and pencil to my patient...we call it "eyeballing" a patient. I chart as I go..at least the flow sheet... In between I give meds (IV) scheduled at this time, make calls (MD, lab etc) if necessary, checking/following up orders, prepping patients for tests/procedures, patient teaching....2- 15 minute break and 1- 30 minute lunch, reassesing patients, finishing charting.

1730 I total my I/O's, PCA pump..clearing pumps (IV, PCA)

1800 double checking orders/charting, making sure patients questions and concerns were addressed

1830 reviewing my report for the next shift

1850-1920 Giving report to the next shift

1923- clock out